Endovascular therapy in addition to standard care (EVT+ SC) has been demonstrated to be more effective than SC in acute ischemic large vessel occlusion stroke. Our aim was to determine the cost-effectiveness of EVT+ SC depending on patients’ initial National Institutes of Health Stroke Scale (NIHSS) score, time from symptom onset, Alberta Stroke Program Early CT Score (ASPECTS), and occlusion location.

A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with both strategies applied in a US setting. Model input parameters were obtained from the literature, including recently pooled outcome data of 5 randomized controlled trials (ESCAPE Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke, EXTEND-IA Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial, MR CLEAN Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands, REVASCAT Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within 8 Hours of Symptom Onset, and SWIFT PRIME Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment). Probabilistic sensitivity analysis was performed to estimate uncertainty of the model results. Net monetary benefits, incremental costs, incremental effectiveness, and incremental cost-effectiveness ratios were derived from the probabilistic sensitivity analysis. The willingness-to-pay was set to 50000/QALY.

Overall,EVT+SCwascost-effectivecomparedwithSC(incrementalcost: 4938, incremental effectiveness: 1.59 QALYs, and incremental cost-effectiveness ratio: 3110/QALY)in100%ofsimulations.Inallpatientsubgroups,EVT+SCledtogainedQALYs(range:0.47–2.12),andmeanincrementalcost-effectivenessratioswereconsideredcost-effective.However,subgroupswithASPECTS≤5orwithM2occlusionsshowedconsiderablyhigherincrementalcost-effectivenessratios( 14 273/QALY and 28812/QALY,respectively)andonlyreachedsuboptimalacceptabilityintheprobabilisticsensitivityanalysis(75.5%and59.4%,respectively).Allothersubgroupshadacceptabilityratesof90%to100%.

EVT+SCiscost-effectiveinmostsubgroups.InpatientswithASPECTS≤5orwithM2occlusions,cost-effectivenessremainsuncertainbasedoncurrentdata.